ACA Delays Decisions in Cardiology

Since the Affordable Care Act became law in 2010, cardiologists have been mired in a fog of uncertainty, leading to delays in making important practice management decisions.

"When I get together with colleagues at national meetings, I get the sense that nobody really understands the future," said Cam Patterson, MD, MBA, chief of the division of cardiology at the University of North Carolina at Chapel Hill.

That uncertainty "throws a wrench into the planning process," including recruitment and benchmark setting, he told MedPage Today.

"It's a major sea change," added Thomas Tu, MD, director of the cardiac catheterization lab for the Louisville Cardiology Group in Louisville, Ky., who notes that physicians are "struggling" to find ways they can be influential in the new environment.

Patterson noted the plight of young cardiologists seeking jobs in a healthcare market unsure of how or when to make its next move.

"It's challenging to hire new recruits when budgetary and human resources decisions are essentially on hold until there is a better understanding of what the ACA will bring," he commented.

Regarding setting benchmarks, Patterson said the days of merely imagining your quality is as good as the next practice or hospital are gone.

Cold, hard data are the new norm, but which data and how best to collect and analyze them, as well as apply the results in a robust and meaningful way, are being worked out slowly.

"As with everyone else, we are scrambling to get a grip on what our quality measures are," Patterson said.

Education and Prevention Will Be Key

Hospitalists, as well as advanced nurse practitioners and physician assistants, can help ease the workload due to the shortage of primary care providers, a shortage that is particularly acute in California, according to C. Noel Bairey Merz, MD, director of the Barbra Streisand Women's Heart Center at Cedars-Sinai Medical Center in Los Angeles.

"If the reform happens the way it is intended, we should have an integrated healthcare system where primary prevention -- management of hypertension, dyslipidemia, diabetes, smoking cessation counseling, and therapeutic lifestyle changes -- is handled at the primary care level," she said.

The truth of the matter, however, is that it takes twice as long to train the average general physician as it does an average nurse practitioner, and four times as long as the average physician assistant.

"A better system is the medical home model, with physician team leaders and physician extenders who work on protocols. The physician extenders would be licensed and would be able to work autonomously within a protocol," she said.

Five years ago, the cardiology department at Geisinger Health Center in Danville, Pa., employed four nurse practitioners or clinical nurse specialists. Today, there are 12 and the department is seeking three more, according to James Blankenship, MD, vice president of the Society for Cardiovascular Angiography and Interventions, as well as an interventional cardiologist at Geisinger.

Blankenship also said that acknowledging the need for more primary care providers is to miss half of the equation. "We will need more specialists, as well."

Given the newly insured patients coming into the system, as well as the aging Medicare population, cardiologists will be stretched pretty thin. But the field of cardiology has been instrumental in advocating teamwork among the different specialties for years, he said. "That's a train that's already on the tracks."

Merz noted an expectation to see more cardiovascular care teams in response to the ACA. Such teams typically consist of a physician leader, nurse practitioners, pharmacists, behavioral experts, rehab professionals, and others.

These teams are vital for the care of high-risk patients such as survivors of angioplasty, bypass surgery, and heart failure, she said, especially since there aren't enough cardiologists to do it all.

Echoing Blankenship, Merz said that cardiologists will probably be busier than ever as heart disease remains the leading killer among men and women as the population ages. She noted a decline in the most severe type of heart attack -- ST-segment elevation MI, or STEMI -- in the Medicare population, a decline that is likely multifactorial, but two reasons stand out as attributable to the decline -- the use of low-dose aspirin and statin therapy for primary and secondary prevention, she said.

"At whatever level these medications are prescribed and managed -- primary care physician, nurse practitioner, cardiologist -- one thing is clear: they work and they should continue to be utilized at the front line of heart disease management," Merz said.

Patients with chronic diseases already consume a great deal of healthcare resources. The other side of that coin is prevention, noted Kathy Berra, MSN, ANP, president of the Preventive Cardiovascular Nurses Association and a nurse at Stanford Prevention Research Center in Stanford, Calif.

"Prevention is a family affair. It's been shown that when women take care of themselves, the health of the family improves."

Emerging as one of the more important gatekeepers for women's health -- including cardiovascular health -- are ob/gyns, Berra said.

Gynecologists have increased their efforts to quiz women about heart disease risk factors such as hypertension, high cholesterol, and diabetes. If red flags are apparent, patients can be referred to primary care providers, internal medicine physicians, or cardiologists.

"Ob/gyns are on the front line of women's health. Perhaps under the ACA model, these specialists will have a closer relationship with cardiologists," Berra told MedPage Today.

Regarding nurses and other care providers in hospitals, they need to be able to educate patients about how to take care of themselves post-discharge, how to understand the importance of their medications, and how to best re-connect with their nonhospital environment.

Readmission is at epidemic proportions and it can be reined in by patient education at the hospital level. Even pharmacists are getting more involved in patient education.

Scott & White Hospital in Temple, Texas, has a program that encourages adherence by waiving drug copays following an education session, according to James Rohack, MD, director of the Center for Healthcare Policy at Scott & White.

Patients on Seniorcare who are on five medications or more are asked if they want to participate in the program. If they agree, they meet with a pharmacist once a month for 15 to 30 minutes. The pharmacist goes over everything about the patient's medication, listens to any concerns, and sends him or her home with new medications, waiving the copay.

"Having no copay is a great benefit for patients on fixed incomes, but it goes beyond that. A little bit of education goes a long way and if patients can be reminded once a month about the importance of taking their medications, we will have fewer hospitalizations," Rohack said.

Accountable Care Organizations

The development of ACOs is probably one of the biggest challenges under the ACA, said Geisinger's Blankenship.

The promise of ACOs is to have better integrated care, less fragmented care among various providers. Part of this integrated care involves incentives to minimize procedures that are either unnecessary or could be replaced with a less costly treatment.

"Having been under a fee-for-service model for a long time, some in cardiology might find the new paradigm challenging," Blankenship suggested.

ACOs are supposed to help take the sting out of moving away from the fee-for-service model by providing the opportunity for better coordinated care -- which should translate into a higher quality of care.

However, ACOs can be difficult to set up, especially from scratch, as they have a large startup cost, he said.

One of the most important aspects of an ACO is to have a solid network of primary care doctors. Patterson, at UNC Chapel Hill, said the uncertainty of whether his state will expand Medicaid has led to the "very aggressive acquisition of primary care practices."

"The goal is to have enough physicians and patients so that we will have a low-cost ACO when we are ready to implement that model. We are going to need about 1 million patients to have an efficient ACO," he said.

But there are also fears that the ACA will deluge cardiologists with paperwork.

"In the clinic, I spend as much time with paperwork as I do with patients -- particularly with Medicare and Medicaid patients," noted John Day, MD, director of Heart Rhythm Services at Intermountain Medical Center in Salt Lake City, Utah. "Many of us are worried we haven't even seen the beginning of the deluge."

The intrusion of paperwork and other government regulations tends to erode the time physicians get to spend with patients -- "one of the primary reasons I wanted to be a doctor," Day said.

In addition, Day said that he and many of his colleagues are disappointed that the ACA did not address malpractice concerns. "Perhaps it's not so much what's in the bill as what is not in the bill," he said.

"Malpractice concerns are real; they scare me every day; it affects how you practice medicine. I don't see how you can rein in costs without addressing the malpractice quagmire," Day told MedPage Today.

Shifting Sands

"For those of us working in the trenches, we have a vague concept of the changes coming down the road," said James A. de Lemos, MD, director of the coronary care unit at Parkland Memorial Hospital in Dallas.

"We seem to be too busy to think about the changes, which leads to one of my biggest worries -- that I won't have prepared my troops well enough," he said.

From a clinical perspective, it's business as usual, with de Lemos and colleagues focused on growth and the development of referrals and procedure services.

"We are concerned, however, that the entire paradigm is going to shift and what we're building today might not be financially sound in the ACO model," de Lemos told MedPage Today.

De Lemos, who is active in cardiovascular biomarker research, suggested that biomarkers will become more important in the ACA era of healthcare.

"It will no longer be prudent to send everyone with a complaint to a cardiologist," he commented. "Biomarker screening may play a role as a triage method to separate out those who merit a trip to the cardiologist from those who can be treated by primary care doctors."

Rohack made these suggestions for getting ready for the changes associated with the ACA:

When caring for uninsured adults, make sure you are aware of the potential benefits with health insurance exchanges, because they may qualify.

Make sure you are aware of impending deadlines regarding the implementation of certain aspects associated with electronic medical records because penalties can be assessed for missing deadlines.

Who Takes the Lead?

There are a lot of moving pieces that will contribute to finding success in the new era of healthcare and leaders must emerge to help forge pathways that others can follow. Hospitalists will be among those leaders, says Jeffrey H. Barsuk, MD, MS, a hospitalist and director of Simulation and Patient Safety for Graduate Medical Education at Northwestern University Feinberg School of Medicine in Chicago.

"At our hospital, we are probably the largest group of physicians involved in healthcare safety, quality, and reform," he said.

The ACA, he told MedPage Today, is starting to have more of an impact on how he and his colleagues position themselves for the future.

In particular, the new bundled payment and fee-per-encounter models are ideal scenarios where hospitalists can make a difference by bridging gaps in the continuity of care and helping to shorten the length of stay without compromising quality.

Hospitalists can, for example, provide smoking cessation counseling for heart patients, discuss the importance of medication adherence, and check to ensure there are no contraindications to the medications or no potential for drug-drug adverse interactions.

Ultimately, though, clinicians at all levels, primary care practitioners and specialists, will need to work closely together because, as interventionalist Tu noted, government intervention that is not well thought out can backfire. The ACA might save money in the short run, Tu said, but in the long term, there is a great potential "to damage the care of patients and harm the profession of medicine. Already many good people don't want to be in the field anymore."

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